3885 Dolomite Dr - Electrical PermitsThis request void ?/z-7 L 7 _ 'D' 1 /
18 months f from l
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{ Licensed Electrical Contractor
Owner
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ired7 ~pe o Rea dy Now Will Notify Inspect
Yes F-1NO Ipr When Ready
I hereby request inspection of above
electrical work installed at
Street Address, Box or Route No.
31M17-8'1-84-9 ? tY
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ec[ion o- Township Name or No. Range No. ntv r,
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Occ ent R(NTI Phone No.
P er S pplier Address
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E ctrl cal C ntractor ( m anY 'met nntractor's I-icense No.
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Mailing Address (Contractor or Owner Making Installation)
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Authorized Signature (Contractor/Owner Making Installation) re Number
tae 5s?
MINNESOTA STATE BOARD OF ELECTRICITY
Griggs-Midway Bldg. - Room N-191
1821 University Ave.. St. Paul. MN 56100
Rhona (612) 297-2111
THIS INSPECTION REQUEST WILL NOT
BE ACCEPTED BY THE STATE BOARD
UNLESS PROPER INSPECTION FEE IS
ENCLOSED-
y REQUEST FOR ELECTRICAL INSPECTION -
?rW C C 5' See instructions for completing this form on back of vellow copy.
1X1. e,nw jr)rk?Apvered by This Request
•,.« LB-00001-03
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pw Add Rep. Type of Building Appliances Wired Equipment Wired
Home Range - Temporary Service
Duplex Water Heater Lighting Fixtures
Apt. Building Dryer Electric Heating
Commercial Bldg. Furnace Silo Unloader
Industrial Bldg. Air Conditioner Bulk Milk Tank
Farm Other pcu yl Other Specify)
t er SpecitY Other Other
Compute Inspection Fee Below
4
d Fee Service Entrance Size k Fee Feeders IS ubfeede.rs A Fee Circuits
100 0 to 100 Amps 0 to 30 Amps 701 0 to 30 Amps
101 to 200 Amps 31 to 100 Amps 10 31 to 100 Amps
Above 200 Amps Above 100-Amps Above 100_Amps
Transtormers Remote Control Circ. O Partial' r Fee
Signs Special Inspection 3
T
Remarks Vr O
AL FEE
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V
Rol - Date .
I
al
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-
(J? - Inspector. hereby
Fna
Date certify that the above
'
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i, nspeetion has been
e
bri
This request void
18 nronths hom
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